CITY OF LA MIRADA Please Check One:

P.O. Box 828 • La Mirada, CA 90637-0828

13700 La Mirada Boulevard • La Mirada, CA 90638 New License
(562) 943-0131 Change of Owner

Change of Address
BUSINESS LICENSE APPLICATION AND OCCUPANCY PERMIT Change of Business Name
Please type or print, sign and return with payment. All sections must be completed.

Business Name (DBA) Start Date in La Mirada

Corporate Name Resale No.
(if applicable)
Federal ID No.
Business Location
(Cannot be P.O. Box per State of California Business & Professional Code-Section 17538.5)
State ID No. (EDD)
Mailing Address
Health Permit
City/State/Zip
State Lic. No
Bus. Phone No. Fax No.
State Lic Type
Email Address Expire Date
Website Job location in La Mirada
Description of Business
NAME(S) AND HOME ADDRESS(ES) OF ALL OWNER(S) PARTNER(S) MANAGING OR CORPORATE OFFICER(S):

Ownership: Sole Proprietor Partnership Limited Liability Corporation Other

Name Title
Home Address Driver Lic. No.
(Cannot be P.O. Box)

Home Phone No. Cell No. Soc. Sec. No.

Name Title
Home Address Driver Lic. No.
(Cannot be P.O. Box)

Home Phone No. Cell No. Soc. Sec. No.

EMERGENCY CONTACT:
Contact Name Phone No.
Address Cell No.
ALARM COMPANY INFORMATION - if applicable:
Contact Name Phone No.
Address Cell No.

PLEASE COMPLETE THE FOLLOWING AND SIGN BELOW FOR OFFICE USE ONLY
(See Fee Schedule for tax amount on back of this form) Business License No.
Enter Gross Receipts, Commissions or Fees Business License Tax
(Estimate for new business)
$ SIC Code Bus. Code

$ Permit Fee $ 90.00 Receipt # Date Received:

Enter Number of Employees (La Mirada)
State CASp Fee $ 1.00 Cash Check No.
# Health Inspector Approved Denied

TOTAL DUE $ Date:

Building Inspector Approved Denied
“I certify/declare under the penalty of perjury under the laws of the State of
California that the foregoing is true and correct.” Date:
Planning Inspector Approved Denied

Signature Title Date:

Fire Inspector Approved Denied

Print Name Date Date:

PLEASE SEE REVERSE SIDE
 CITY OF LA MIRADA
P.O. Box 828 • La Mirada, CA 90637-0828
13700 La Mirada Boulevard • La Mirada, CA 90638 • (562) 943-0131

BUSINESS LICENSE TAX WORKSHEET

General Businesses (Retail, Wholesale, Professional, Services, Contractors):

Bracket $1 - $50,000 $50,001 - $500,000 $500,001 - $9,100,000 $9,100,001 and above

Enter your gross receipts
- -
for the previous Year:
Subtract: - $50,000 $500,000 -
Multiply: - .0002 .0001 -
Add: - $50 $140 -
Business License Tax $50 $1,000
Due*

*Minimum Business License Tax Due is $50 and maximum is $1,000.

Manufacturers:

Bracket $1 - $500,000 $500,001 - $5,000,000 $5,000,001 - $40,000,000 $40,000,001 and above

Enter your gross receipts
- -
for the previous Year:
Subtract: - $500,000 $5,000,000 -
Multiply: - .00005 .00002 -
Add: - $75 $300 -
Business License Tax $75 $1,000
Due*

* Minimum Business License Tax Due is $75 and maximum is $1,000.

Warehouses:

Bracket Below 100,000 sq. 100,000 sq. and above

Enter your square footage: -
Multiply: $.01 -
Business License Tax $1,000
Due*

* Minimum Business License Tax Due is $75 and maximum is $1,000.

Pick Up and Deliver Service (Located out of City):

Bracket $1 - $50,000 $50,001 - $4,800,000 $4,800,001 and above

Enter your gross receipts
- -
for the previous Year:
Subtract: - $50,000 -
Multiply: - .0002 -
Add: - $50 -
Business License Tax $50 $1,000
Due*

*Minimum Business License Tax Due is $50 and maximum is $1,000.

Coin Operated Machines (Located in the City):

Bracket $1 - $10,000 $10,001 and above

Enter your gross receipts
-
for the previous Year:
Subtract: - $10,000
Multiply: - .01
Add: - $50
Business License Tax $50
Due*

*Minimum Business License Tax Due is $50.

Updated: 12.5.12
 F o r S t a f f U s e
La Mirada
Community Development Department Date ___________ ‰ Business License
13700 La Mirada Boulevard
La Mirada, CA 90638 By ___________ ‰ Home Occupation Permit
(562) 943-0131
‰ Association Approval

ZONING CLEARANCE/PLAN CHECK APPLICATION

(Business License / Home Occupation Permit)

BUISNESS ADDRESS

_______________________________________________________ La Mirada, California, 90638

BUSINESS DESCRIPTION

G
E
N
E
R
A
L
BUSINESS OWNER(S) (Please print) BUSINESS PHONE CELL PHONE
I
N HOME PHONE EMAIL
F
O MAILING ADDRESS CITY STATE ZIP
R
M
PROPERTY OWNER(S) (Please print) BUSINESS PHONE CELL PHONE
A
T
HOME PHONE EMAIL
I
O
PROPERTY OWNER(S) ADDRESS CITY STATE ZIP
N

DOES THE PROPERTY HAVE DEED RESTRICTIONS AFFECTING THE USE THEREOF, IF SO DESCRIBE:

CERTIFICATE AND AFFIDAVIT OF APPLICANT: I certify that all statements made on this application are true and
complete to the best of my knowledge. I understand that any false statements may result in denial of the requested
license/permit or revocation of any issued license/permit. I further certify that I am, or have permission by, the property
owner to conduct the proposed business applied for herein.

APPLICANT SIGNATURE DATE

City of La Mirada
February 2010